Kowaleski v. Allstate Ins. Co.

569 A.2d 815, 238 N.J. Super. 210
CourtNew Jersey Superior Court Appellate Division
DecidedFebruary 5, 1990
StatusPublished
Cited by10 cases

This text of 569 A.2d 815 (Kowaleski v. Allstate Ins. Co.) is published on Counsel Stack Legal Research, covering New Jersey Superior Court Appellate Division primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Kowaleski v. Allstate Ins. Co., 569 A.2d 815, 238 N.J. Super. 210 (N.J. Ct. App. 1990).

Opinion

238 N.J. Super. 210 (1990)
569 A.2d 815

STACY A. KOWALESKI, PLAINTIFF-RESPONDENT,
v.
ALLSTATE INSURANCE CO., DEFENDANT-APPELLANT.
CARMEN FERNANDEZ, PLAINTIFF-RESPONDENT,
v.
ALLSTATE INSURANCE CO., DEFENDANT-APPELLANT.
MICHAEL A. MARRAZO, PLAINTIFF-RESPONDENT,
v.
ALLSTATE INSURANCE CO., DEFENDANT-APPELLANT.

Superior Court of New Jersey, Appellate Division.

Argued December 20, 1989.
Decided February 5, 1990.

*211 Before Judges GAULKIN, DREIER and SCALERA.

Thomas F. McGuane argued the cause for appellant Allstate Insurance Co., (Carpenter, Bennett & Morrissey, attorneys; John E. Keale, of counsel, Thomas F. McGuane, on the brief).

John Paul Dizzia argued the cause for respondent Stacy A. Kowaleski (John Paul Dizzia, on the brief).

Howard Duff argued the cause for respondent Carmen Fernandez (Nemergut & Duff, attorneys; Howard Duff, on the brief).

Charles A. Zahn argued the cause for respondent Michael A. Marrazo (Shore & Zahn, attorneys; Charles A. Zahn, on the brief).

Francis & Berry, attorneys, filed a brief Amicus Curiae on behalf of the New Jersey Automobile Full Insurance Underwriting Association (Hugh P. Francis, of counsel; Joan Bannan Lorio, on the brief).

The opinion of the court was delivered by DREIER, J.A.D.

Defendant Allstate Insurance Co. has appealed from three adverse summary judgments entered by two Middlesex County Superior Court judges. We have been informed that there have been several additional decisions concerning similar issues in Middlesex County and elsewhere, all unreported, consistent with and opposed to the statutory interpretation advanced by the trial judges in the cases before us. As the three cases before us all raise similar issues, we have consolidated them for the purpose of this opinion.

In each of the cases before us the respective trial judge determined that an insurer's failure to comply with the notice requirements set forth in N.J.S.A. 39:6A-5(b) acts as a bar to the insurer's right to contest payment for medical bills submitted under the Personal Injury Protection (PIP) section of defendant's automobile insurance policy. See N.J.S.A. 39:6A-4a. *212 In order to provide the factual basis for our interpretation of the statute, we will briefly describe the underlying facts in each of the three cases.

Kowaleski claim:

On November 2, 1984, the plaintiff, Stacy A. Kowaleski, was injured in an automobile accident. Allstate, as the servicing carrier for the New Jersey Automobile Full Insurance Underwriting Association (JUA), provided PIP coverage and paid many of plaintiff's medical bills. The problem commenced on January 21, 1986 when Ms. Kowaleski began to incur further and substantial medical expenses. On that date she consulted Ira M. Klemons, D.D.S. concerning pains she claimed to be experiencing in or near her face and neck and temporomandibular joint (TMJ). Dr. Klemons and his associate, Janet Crain, D.M.D. treated Ms. Kowaleski at the TMJ Trauma and Headache Center operated by them in Parlin, New Jersey, for TMJ problems from January 1986 to May 16, 1986. They also obtained diagnostic electromyography from Martin Feldman, M.D. Allstate asserts that discovery has revealed that they regularly referred patients to Dr. Feldman for electromyography, and that myelogram readings were rendered by Dr. Feldman or his corporation on one of four duplicated reports, all of which recommended additional treatment. Ms. Kowaleski submitted the bills to Allstate with a report indicating that her need for TMJ treatment was causally related to her November 2, 1984 car accident. Soon after receipt of most of those bills, Allstate by letter dated April 29, 1986 informed Ms. Kowaleski that she should schedule an "independent" medical exam with Robert Bonda, D.M.D. The letter informed her that Allstate's

doctor will examine you under the `No Fault' statute. This examination is necessary in order for us to consider payment of benefits under No Fault.

Ms. Kowaleski, however, did not schedule the examination, and Allstate sent a second similar notice requesting her to call Dr. Bonda to arrange an appointment for an examination. This letter also was disregarded. By letter dated July 8, 1986 Allstate advised Ms. Kowaleski that it had suspended her *213 benefits pending an examination with Dr. Bonda. Finally on July 31, 1986 she submitted to the examination.

Dr. Bonda concluded that none of plaintiff's TMJ treatment was for a condition causally related to the November 2, 1984 accident. By letter dated September 3, 1986 Allstate enclosed a copy of Dr. Bonda's report and informed Ms. Kowaleski that it "will not honor any bills for treatment given by Dr. Klemons, Crain or Feldman or for any costs dealing with TMJ care."

One month later Ms. Kowaleski filed this action to compel Allstate to pay any present unpaid and future medical bills incurred as a result of her accident, as well as counsel fees, costs, and interest. Allstate timely filed its answer denying the allegations of the complaint and plaintiff moved for summary judgment.

The trial judge determined that:

The statute says that a carrier has 30 days in which to deny the claim and give their reasons or they can ask for a forty-five day extension within that 30 days and in both instances they have to give the reasons for this and they did not, in fact, do it and they're absolutely bound by the statute which is 39:6A-5.

He therefore precluded Allstate from further contesting these bills. Judgment was thereafter entered in the sum of $1,925 plus interest, costs and attorneys' fees. After Allstate's unsuccessful motion to vacate the order for summary judgment and plaintiff's successful application to fix the amount of counsel fees and interest, judgment was entered in the amount of $3,752.01.

Fernandez claim:

On November 5, 1986, plaintiff Carmen Fernandez received injuries in an automobile accident. As in the Kowaleski case, Allstate as servicing carrier for the JUA paid Ms. Fernandez's medical bills from November 19, 1986 through January 29, 1987. On February 4, 1987 she allegedly incurred additional medical expenses for treatment by Dr. Klemons for TMJ problems. The treatment continued through June 6, 1987, and bills for the TMJ treatment at the TMJ Trauma and Headache *214 Center and for diagnostic x-rays by a Dr. Ashendorf were first received by Allstate on March 11, 1987. Although plaintiff contends that she submitted to a PIP examination by an Allstate orthopedist who diagnosed cervical sprain and TMJ Syndrome (causally related to the accident), the record before us contains no reference to this examination.

By letter of April 6, 1987 Allstate informed Ms. Fernandez that an out-of-county examination had been arranged for her by Dr. Rauof Mansour on April 25, 1987. Plaintiff's attorney, however, objected to the location of the examination and contended that it must be given locally.[1] Allstate nevertheless informed plaintiff that if she did not attend the examination, benefits would be suspended. Plaintiff filed her complaint on August 28, 1987, but on the return date of an order to show cause, agreed to submit to the examination by Dr. Mansour. The examination report stated that

there is no objective evidence presented to show that [Ms. Fernandez] required ... any dental services by any dentist....

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Bluebook (online)
569 A.2d 815, 238 N.J. Super. 210, Counsel Stack Legal Research, https://law.counselstack.com/opinion/kowaleski-v-allstate-ins-co-njsuperctappdiv-1990.